Research Article

Polypropylene Manual Knotting for Closure of Appendix Stump During Laparoscopic Appendectomy


  • Özlem Zeliha Sert

Received Date: 04.05.2017 Accepted Date: 08.08.2017 Turk J Colorectal Dis 2017;27(3):72-75


To evaluate the results of patients in whom the appendix stump was closed with a hand-made loop using polypropylene suture during laparoscopic appendectomy.


The files of 25 patients who underwent laparoscopic appendectomy in the Erciş State Hospital Clinic of General Surgery between August 2016 and October 2016 were retrospectively screened. During surgery, the appendix stump was closed with an extracorporeal knot using polypropylene. Patients were assessed for age, sex, American Society of Anesthesiology (ASA) score, smoking history, operation time, length of hospital stay, conversion rate to open procedure, postoperative complications, and follow-up. Patients were followed until skin sutures were removed.


Mean age was 31±2 years and there were 16 women and 9 men in this study. Seventeen patients were ASA I, six were ASA II, and two were ASA III. Thirty percent of the patients were smokers. Mean operation time was 35 minutes and mean hospital stay was 1.4 days. Two patients (14%) had perforated appendicitis, the rest were not perforated (86%). Postoperative complications included wound infection in one patient, and subcutaneous emphysema and persistent pneumoperitoneum in one patient. Follow-up time was 14 days for all patients.


The reliability of appendix stump closure using polyglactin or silk suture by manual knotting during laparoscopic appendectomy has been reported previously. This study demonstrates that appendix stump closure using polypropylene suture is reliable with some limitations.

Keywords: Acute appendicitis, laparoscopic appendectomy, manual knot, polypropylene


Acute appendicitis is the most common reason for emergency abdominal surgery. Open appendectomy remains the gold standard in the treatment of appendicitis. In 1983, Semm1 first proposed laparoscopic appendectomy as an alternative to open appendectomy. Some studies have demonstrated that laparoscopic appendectomy provides better cosmetic results, shorter hospitalization time, less pain, and faster return to daily life relative to open appendectomy.2,3 Moreover, it has been proven to be a good diagnostic tool for suspicious cases, especially among women.2,4 Closing the appendiceal stump is the most important step of the appendectomy procedure because most complications develop as a result of leakage from the stump.

Polypropylene suture material is non-absorbable, and one of its advantages is that it elicits very little tissue reaction.5 Furthermore, it is less likely to promote bacterial colonization due to its monofilament construction and uninterrupted surface.6 Compared to natural products, polypropylene causes less inflammation.7

Many methods are used to close the stump during laparoscopic appendectomy. Intracorporeal knotting, endoloop, polymeric clips, titanium clips, and endostapler are the most commonly employed.8,9,10 There are numerous studies in the literature comparing these methods, particularly in terms of operation time and complications. The aim of the present study was to present outcomes of closing the appendiceal stump with polypropylene suture.

Materials and Methods

The files of 25 patients for whom an extracorporeal knot made with polypropylene was used to close the appendix stump during laparoscopic appendectomy in the Erciş State Hospital Clinic of General Surgery between August 2016 and October 2016 were retrospectively screened.

Data regarding the patients’ age, sex, American Society of Anesthesiology (ASA) score, smoking history, operation time, length of hospital stay, conversion rate to open procedure, postoperative complications and follow-up time were recorded using Microsoft Excel 2016 software. In accordance with the Declaration of Helsinki, informed consent was obtained from all patients prior to the study.

First generation cephalosporin was given as prophylaxis. All procedures were performed by the same surgeon and under general anesthesia. A 10-mm infraumbilical trocar, 5-mm left paramedian trocar, and 5-mm suprapubic trocar were placed in all operations. Reusable tools were used. A knot was manually prepared preoperatively using 2/0 polypropylene suture (Figure 1). The appendiceal mesentery was cut using Enseal (Ethicon, New Jersey, USA). The base of the appendix was extracorporeally ligated twice from the distal end using 2/0 polypropylene suture (Figures 2, 3). The proximal end was cut using Enseal, the appendix was placed in a retrieval bag formed from a surgical glove and removed through the 10-mm trocar. Operation time was accepted as the period from anesthesia induction to extubation. Drains were only placed in patients with perforation. Patients were discharged postoperatively when their overall condition was good, vital signs were stable, and oral intake was normal. Patients were followed for a period of 14 days, until the skin sutures were removed.


The mean age of the patients was 31±2 years. The study included 16 females and 9 males. Seventeen patients were ASA I, six were ASA II, and two were ASA III. The smoking rate was 30%. Mean operation time was 35 minutes and mean hospital stay was 1.4 days. Two of the 25 patients (14%) had perforated appendicitis; perforation was not detected in the remaining patients (86%). Despite perforation in two patients, none of the operations were converted to open procedures. Postoperative complications included wound infection in one patient and subcutaneous emphysema in one patient. The patient with subcutaneous emphysema was rehospitalized and treated conservatively with antibiotics. There was no mortality. Follow-up time was 14 days for all patients (Table 1).


Unlike laparoscopic cholecystectomy, laparoscopic appendectomy has not yet been accepted as a gold standard treatment due to difficulties encountered when closing the stump. Although the laparoscopic appendectomy technique is well established, many different techniques are used in the procedure, including in trocar placement and stump closure. Selecting the most reliable method for stump closure is the crux of laparoscopic appendectomy. Surgical stapler or endoloop have been used in previous studies to close the stump.11,12 Although using an endostapler is a simple method of closing the stump, it is more expensive when compared with other methods.11,13,14,15 Partecke et al.15 showed that using non-absorbable polymeric clips is more reliable and less expensive than the endostapler. Other studies have reported Hem-o-lok clips as a reliable method.4,15 However, these clips are not suitable when the appendix exceeds 1 cm in diameter. Arcovedo et al.11 compared extracorporeal knotting and stapler use and found that only 1 in 63 patients whose stumps were closed with extracorporeal knot developed intra-abdominal abscess. They concluded that the extracorporeal knot is both inexpensive and reliable for appendiceal stump closure.11 The use of simple, rapid, reliable, and less expensive metal clips has also been proposed as an alternative method of closing the stump.16 The results of using extracorporeal technique with polypropylene suture for stump closure were favorable after 14 days of follow-up in our study; however, a comparison of reliability was not possible due to the paucity of data in the literature.

Mayır et al.17 performed manual knotting with polyglactin suture for closing the appendix stumps in all of their patients, regardless of appendix diameter, and reported no cases of leakage from the stump.

Mantoglu et al.18 used polypropylene for stump closure in their study, but did not fully establish its reliability. There are few studies in the literature on the reliability of using polypropylene suture for appendiceal stump closure in laparoscopic appendectomy.

Although the present study did not include a control group, we found that using polypropylene suture for appendiceal stump closure during laparoscopic appendectomy resulted in no stump leakage.

A review by Mayir et al.19 of the available literature data showed that all of the methods were comparably reliable. Therefore, it was determined that inexpensive and easily applicable methods should be the first choice. Nevertheless, the authors stated that the final decision depends on surgeon experience, availability of equipment, cost, and the extent of appendiceal inflammation.19

Previous studies have investigated the reliability of manually closing the appendiceal stump in laparoscopic appendectomy using polyglactin or silk suture. Limitations of this study are the small sample size, retrospective study design, and short follow-up time. In summary, we determined that manual closure of the appendiceal stump during laparoscopic appendectomy using a polypropylene extracorporeal knot was reliable.


Ethics Committee Approval: Retrospective study.

Informed Consent: Consent form was filled out by all participants.

Peer-review: Internally peer-reviewed.

Financial Disclosure: The authors declared that this study received no financial support.

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